Jehn-Yu Huang

Diagnostic power of optic disc morphology, peripapillary retinal nerve fiber layer thickness, and macular inner retinal layer thickness in glaucoma diagnosis with fourier-domain optical coherence tomography.

PurposeTo evaluate the capability of the optic disc, peripapillary retinal nerve fiber layer (P-RNFL), macular inner retinal layer (M-IRL) parameters, and their combination obtained by Fourier-domain optical coherent tomography (OCT) in differentiating a glaucoma suspect from perimetric glaucoma. MethodsTwo hundred and twenty eyes from 220 patients were enrolled in this study. The optic disc morphology, P-RNFL, and M-IRL were assessed by the Fourier-domain OCT (RTVue OCT, Model RT100, Optovue, Fremont, CA). A linear discriminant function was generated by stepwise linear discriminant analysis on the basis of OCT parameters and demographic factors. The diagnostic power of these parameters was evaluated with receiver operating characteristic (ROC) curve analysis. The diagnostic power in the clinically relevant range (specificity ≥80%) was presented as the partial area under the ROC curve (partial AROC). ResultsThe individual OCT parameter with the largest AROC and partial AROC in the high specificity (≥80%) range were cup/disc vertical ratio (AROC=0.854 and partial AROC=0.142) for the optic disc parameters, average thickness (AROC=0.919 and partial AROC=0.147) for P-RNFL parameters, inferior hemisphere thickness (AROC=0.871 and partial AROC=0.138) for M-IRL parameters, respectively. The linear discriminant function further enhanced the ability in detecting perimetric glaucoma (AROC=0.970 and partial AROC=0.172). ConclusionsAverage P-RNFL thickness is the optimal individual OCT parameter to detect perimetric glaucoma. Simultaneous evaluation on disc morphology, P-RNFL, and M-IRL thickness can improve the diagnostic accuracy in diagnosing glaucoma.

The Effect of Topical Autologous Serum on Graft Re-epithelialization After Penetrating Keratoplasty

PURPOSE To analyze factors influencing corneal graft re-epithelialization after penetrating keratoplasty (PK) and evaluate the effect of topical autologous serum in promoting graft re-epithelialization. DESIGN Prospective interventional study. METHODS We analyzed 165 eyes of 165 patients who underwent PK between January 1, 2005 and December 31, 2007. Patients were divided into 2 groups according to routine use or non-use of postoperative 20% topical autologous serum. Postoperative slit-lamp examination after fluorescein staining was performed, and graft re-epithelialization time was recorded. Recipient/donor characteristics, surgical variables, and topical use of autologous serum were analyzed for their effects on post-PK graft re-epithelialization. Statistical analysis was performed by univariate and multivariate regression analysis using the ordinal logistic fit model to assess the potential risk factors influencing graft re-epithelialization after PK. RESULTS In univariate analysis, diabetes mellitus (DM), longer death-to-storage time and death-to-surgery time of the donor, and larger recipient size significantly delayed graft re-epithelialization (P < .05). Use of autologous serum significantly expedited graft re-epithelialization (P = .004). In multiple regression analysis, only DM in the recipient (odds ratio [OR] = 5.10, P < .001), postoperative use of autologous serum (OR = 0.54, P = .046), and larger graft size (OR = 4.44, P < .001) influenced graft re-epithelialization. The beneficial and healing effect of autologous serum is particularly significant in diabetic recipients and larger grafts. CONCLUSIONS Several factors may influence graft re-epithelialization after PK. Graft re-epithelialization time was longer in diabetic recipients and larger grafts. Use of autologous serum may be a beneficial strategy in these patients with potentially delayed epithelial healing.

Association Between High Myopia and Progression of Visual Field Loss in Primary Open-angle Glaucoma

BACKGROUND/PURPOSE Taiwan has a very high prevalence rate of myopia. We retrospectively studied the influence of myopia on the progression of visual field (VF) loss in primary open-angle glaucoma (POAG) patients. METHODS We studied 515 POAG patients for a minimum follow-up period of 5 years. VF examination was performed with Humphrey perimeter, 30-2 SITA standard program, every 6 months. A point-wise numerical comparison was applied to judge the VF changes. Test points showing more than 1.0 dB of sensitivity loss in mean defect were identified. A location was considered to have progression if it was detected on two consecutive visits. Progression of VF loss was confirmed if three or more test points deteriorated. Multivariate logistic regression was used to evaluate the association between progression of VF loss and various risk factors. RESULTS There were 262 cases. Progression of VF loss occurred in 57 eyes (21.8%) during the 5-year follow-up period. Logistic regression revealed that the deterioration was associated with older age, higher mean intraocular pressure, larger vertical cup-to-disc ratio, and greater myopic refraction status. The incidence of VF loss progression was 15.1% in the group of eyes with myopia less than -3 D, 10.5% in the group with -3 D to -6 D, 34.4% in the group with -6 D to -9 D, and 38.9% in the group with myopia greater than -9 D. CONCLUSION POAG patients with myopia greater than -6 D had a greater progression of VF loss.

Racial and ethnic disparities in adherence to glaucoma follow-up visits in a county hospital population.

OBJECTIVES To identify predictors of inconsistent attendance at glaucoma follow-up visits in a county hospital population. METHODS Prospective recruitment from August 1, 2008, through January 31, 2009, of 152 individuals with glaucoma, with 1-to-1 matching of patients (those with inconsistent follow-up) and controls (those with consistent follow-up). Data were collected via oral questionnaire. Survey results were correlated with attendance at follow-up examinations, using the t test, χ(2) test, and multivariate stepwise logistic regression analysis to calculate the odds ratios (ORs) and 95% confidence intervals. RESULTS After adjusting for covariates in the logistic regression analysis, factors independently associated with inconsistent follow-up included black race (adjusted OR, 7.16; 95% confidence interval, 1.64-31.24), Latino ethnicity (adjusted OR, 4.77; 1.12-20.29), unfamiliarity with necessary treatment duration (adjusted OR, 3.54; 1.26-9.94), lack of knowledge of the permanency of glaucoma-induced vision loss (adjusted OR, 3.09; 1.18-8.04), and perception that it is not important to attend all follow-up visits (adjusted OR, 3.54; 1.26-9.94). CONCLUSIONS Demographic factors, including race and ethnicity, may directly or indirectly affect adherence to recommended glaucoma follow-up visits. Lack of information regarding irreversible vision loss from glaucoma, need for lifelong treatment, and lack of visual symptoms may be significant barriers to follow-up in this population. Targeted glaucoma education by physicians may improve follow-up, thereby decreasing the morbidity associated with glaucomatous disease.

Clinical Outcomes in Cytomegalovirus-Positive Posner-Schlossman Syndrome Patients Treated With Topical Ganciclovir Therapy

PURPOSE To evaluate the clinical characteristics and therapeutic outcomes of cytomegalovirus (CMV)-positive Posner-Schlossman syndrome patients undergoing topical ganciclovir treatment. DESIGN Retrospective, comparative, and interventional case series. METHODS One eye of each of 126 consecutive Posner-Schlossman syndrome patients was investigated using aqueous polymerase chain reaction (PCR) between January 2006 and June 2013. The initial presentations and follow-up data of the CMV-positive patients (68 eyes) and CMV-negative patients (58 eyes) were compared. RESULTS Severe endothelial cell loss (P < .001) and a higher number of eyes requiring glaucoma filtering surgery (P = .017) were observed in CMV-positive Posner-Schlossman syndrome patients. All CMV-infected eyes treated with continual topical 2% ganciclovir exhibited an undetectable CMV level at the following taps. During follow-up, the average number of antiglaucomatous agents decreased, and a similar frequency of intraocular pressure (IOP) spikes was observed in both groups (P = .358). Patients with CMV-positive eyes with a disease duration over 5 years were likely to require glaucoma surgery (P = .024, log-rank test). All patients receiving surgery exhibited CMV-negative PCR during the IOP attack, but experienced severe peripheral anterior synechiae and pigment clogging. Both groups exhibited a similar endothelial cell decrease (P = .243) and probability of progressive endothelial cell loss (P = .219, log-rank test). CONCLUSION Ganciclovir treatment was effective for clearing the viral load, assisting the IOP control, and preserving the corneal endothelium of CMV-positive Posner-Schlossman syndrome patients. Early diagnosis and proper treatment could decrease the risk of advanced glaucoma and avoid glaucoma surgery in long-lasting cases.

Ocular hypotensive effect and safety of brinzolamide ophthalmic solution in open angle glaucoma patients.

BACKGROUND AND PURPOSE Brinzolamide is a new topical carbonic anhydrase inhibitor for intraocular pressure (IOP) control. It has high inhibitory activity against human carbonic anhydrase II, which is the key isoenzyme regulating aqueous humor production. We conducted this study to compare the ocular hypotensive effect and safety of 1% brinzolamide versus that of 0.5% timolol twice daily. METHODS In a double-masked design, 50 open angle glaucoma patients who had a baseline IOP between 20 to 30 mm Hg were randomized to receive either 1% brinzolamide ophthalmic solution or 0.5% timolol twice daily. After completing a 2-week pre-study screening period, patients were scheduled to receive 6 weeks of treatment. Visual acuity, IOP, slit-lamp biomicroscopy, corneal thickness, refraction status, blood pressure, heart rate, and treatment-related signs and symptoms were evaluated at follow-up visits. The eye selected for treatment was the one with the higher baseline IOP, or the right eye if the IOPs were the same in both eyes. The fellow eye served as control. RESULTS 48 patients completed the study, and there were 24 patients in each group. A significant decrease in mean IOP was found after 6 weeks of treatment in both the brinzolamide group (-17.0%) and the timolol group (-19.7%), with no significant between-group difference in the control of IOP. The central corneal thickness of treatment eyes, measured by ultrasound pachometry, had not changed after 6 weeks of brinzolamide treatment. The study medications were generally well tolerated and no serious adverse reactions occurred during the 6-week study period. CONCLUSION When used twice a day, topical brinzolamide is as effective as 0.5% timolol in lowering IOP in patients with open angle glaucoma.

Intraocular pressure measurement with the noncontact tonometer through soft contact lenses.

PurposeTo assess the accuracy of measuring intraocular pressure (IOP) through a soft contact lens (SCL) with different refractive powers using a noncontact tonometer (NCT). MethodsThirty-two healthy adult volunteers free of glaucoma or corneal disease participated in this study. IOP was measured in the right eyes without SCLs and with different lens powers, from −3.0 to −12.0 D as measured by NCT. IOP of the left eyes was also measured, as an internal control. Corneal curvature was measured in both eyes using an autokeratometer. Sixteen volunteers wore one brand of SCL (group A) and the other 16 wore a different brand, with 2 different curvatures (groups B and C). Statistical data were analyzed by SPSS using the Wilcoxon signed rank test for comparison of IOP readings and multiple linear regression analysis for the relationship among power of contact lenses, corneal power, and difference in IOP measurements. ResultsThe difference in mean IOP between eyes without lenses and those with lenses was statistically significant in lens with −6.0 D and below in all 3 groups. The decrease in IOP significantly correlated with the refractive power of contact lenses in all 3 groups. The difference in IOP measurements was influenced by the mean K in group A but not in group B or C. There was no statistically significant difference in the IOP measurements in the left eyes or in the mean K between the right and left eyes. ConclusionsIOP measurement through myopic SCLs by NCT may be inaccurate and tends toward underestimation, especially in high myopic lenses. A strong relationship exists between IOP reduction and myopic lens power.

Combined Tractional and Rhegmatogenous Retinal Detachment in Proliferative Diabetic Retinopathy in the Anti-VEGF Era

Purpose. To investigate the clinical features, surgical outcomes, and prognostic factors of combined rhegmatogenous and tractional detachment (combined RD) in proliferative diabetic retinopathy (PDR) in recent years. Methods. Medical records of PDR and combined RD treated with vitrectomy from 2008 to 2013 were retrospectively reviewed. Results. A total of 57 eyes from 49 patients were included. Nine eyes had received panretinal photocoagulation (PRP) and 7 eyes had intravitreal bevacizumab (IVB) within 3 months before RD developed. Thirty-eight eyes (66.7%) had ≧3 sites of broad adhesion of fibrovascular proliferation (FVP). Thirty-three eyes (57.9%) showed active FVP. Thirty-four eyes (59.6%) had extent of RD involving 3 or 4 quadrants. The primary reattachment rate was 93.0%, and the final visual acuity (VA) improved by more than 3 lines in 80.7% of eyes. Neovascular glaucoma occurred in 4 eyes postoperatively. Poor preoperative VA, severe vitreoretinal adhesion, and broad extent of RD had significant correlation with poor visual outcomes. Conclusion. PRP or IVB might play a role in provoking combined RD. The anatomical and functional success rates of surgery were high. Poor preoperative VA and severe proliferations predicted poor visual outcomes.

Pupil centroid shift and cyclotorsion in bilateral wavefront-guided laser refractive surgery and the correlation between both eyes.

BACKGROUND/PURPOSE Accuracy of ocular alignments is emphasized in laser refractive surgery. We evaluate pupil centroid shift and cyclotorsion and the correlation between both eyes in bilateral wavefront-guided laser refractive surgery. METHODS A retrospective study was performed to analyze pupil centroid shift and cyclotorsion using an iris registration system of Zyoptix 100 platform in 186 eyes of consecutive 93 patients at National Taiwan University Hospital. Pearsons correlation analysis was used. RESULTS The mean pupil centroid shift was 0.179±0.096mm, and 42.2% of eyes had more than 0.2mm shift between wavefront measurement with dilated pupil and laser ablation with undilated pupil. When the pupil was pharmacologically dilated, pupil centers predominantly shifted to inferonasal direction (59% of eyes). The vertical shift was larger than the horizontal shift. The correlations between both eyes in horizontal and vertical shifts were statistically significant, indicating a symmetric mirror pattern. A good opposite correlation of pupil centroid shifts was observed between in wavefront measurement and in laser treatment. The mean amount of cyclotorsion between the seated and supine positions was 3.22±2.53° with a maximum of 13.51°. A total of 112 eyes (60.2%) had cyclotorsion > 2°, while 39 eyes (21.0%) had cyclotorsion > 5°. Moderate correlation was observed between cyclotorsion of both eyes and was statistically significant. CONCLUSION Inferonasal pupil centroid shift as the pupil pharmacologically dilated and a significant amount of cyclotorsion with good correlation between both eyes was observed in refractive surgery and could be compensated by iris registration.

Patient-related and system-related barriers to glaucoma follow-up in a county hospital population.

PURPOSE To identify the barriers to glaucoma follow-up and to assess how ethnicity influences the effect of such barriers among patients in a county hospital population. METHODS This cross-sectional study included 152 patients, 76 with poor clinic follow-up and 76 with good clinic follow-up, who were recruited at the San Francisco General Hospital glaucoma clinic as part of a case-control study. All subjects were required to be established patients with glaucoma initially seen and diagnosed in the clinic at least 1 year before enrollment. An oral questionnaire pertaining to the barriers to follow-up for glaucoma, as well as patient ethnicity, was administered to all participating subjects. The main outcome measure was the prevalence of significant barriers to follow-up, both overall and stratified by ethnicity. RESULTS The most prevalent barriers to follow-up included long clinic waiting times (75%), appointment scheduling difficulties (38%), the effect of other medical or physical comorbidities (29%), and difficulties related to medical interpretation (23%). While several barriers were cited as being important across different ethnicities, Latinos and Asian-Pacific Islanders were particularly affected by difficulties related to medical interpretation (P = 0.0001) and long waiting times in the clinic (P = 0.048). CONCLUSIONS Understanding patient-reported barriers to glaucoma follow-up and their variation based on ethnicity may give providers insight as to why patients do not adhere to follow-up recommendations. Strategies to improve follow-up may include reduced clinic wait times, simplified appointment scheduling, and provision of appropriate education and counseling regardless of the patients native language and ethnicity.